Therapy Evaluation Form Page 3

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therapy evaluation form
MEDICAL HISTORY:
1. Please give a brief medical history of your child.
2. Is your child currently taking any medications?
Yes / No
(If yes, please list)
3. Does your child have any known allergies?
Yes / No
(If yes, please list)
4. Has your child’s hearing been evaluated recently?
Yes / No
(If yes, when, by whom and what were the results?)
/
/
5. Does your child have any di culty falling asleep or staying asleep?
Yes / No
(If yes, please list)
Are there any other precautions we should know about that are not described above?
3

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